ConnectU
Which resource is the controlled source for published claims desk-level procedures?
ConnectU
In Tapestry AP, what does AP stand for?
Adjudication Processing.
Contract Design Interpretation Document
Which hold code identifies an ambulance claim that needs authorization review?
AUH12, Hold, Authorization not found
What does RFI stand for?
Request for Information
What claim specific-search term can help you find a procedure quickly?
The claim code
You have a member’s MRN but no claim number. Which activity helps you find their claim history?
Member Inquiry
In the CDID, which provider identifier do you enter to search for a contract?
The provider's Tax ID number (TIN)
Which information code identifies a non-member ambulance/transportation claim?
CI722, INFO, NON-MEMBER AMBULANCE/TRANSPORTATION.
Does an RFI, by itself, mean that a claim has been denied?
No. It requests documentation or clarification needed to process the claim
What day is ConnectU updated?
Monday's when there is no holiday
Which feature lets you check coverage while keeping your claim open?
A CDID matches the provider’s name. Name two other details you must check against the claim.
Any two: effective date, service, NPI, or line of business (LOB).
For the facility-to-facility copay override task, for non-Emergency Transport, what must you check before overriding?
Verify that the copay is greater than zero
Name two common reasons to request information on an ambulance claim.
Any two: missing medical records, missing or invalid trip codes, itemized bill issues, invalid TIN, missing NPI, proof of medical necessity, or an improper medical form.
Where in ConnectU can you look for recently introduced or revised procedures?
Revision history
What is the name of the location where you find the date of service, coverage, member’s DOB, and triplet information?
The Storyboard
After finding the appropriate CDID, which columns should you review for the payment?
Pricing Method, Rate, and Lesser of
In the CLH58 task, what value goes in the Copay override field, and what do you validate afterward?
Enter 0. After Stop Overriding, validate that the copay reflects zero.
Which hold code means SEND RFI LETTER, and which information code means RFI REQUEST NEEDED?
CH118 is the hold code. CI418 is the information code.
A teammate's verbal instructions conflict with the published DLP. What should you do?
Follow the published DLP and raise the conflict to your lead or supervisor for clarification.
When checking benefits for an older claim, which date should drive your inquiry?
The date of service, using the member's applicable plan
A CDID lists a flat-fee pricing methodology. Which column do you find the individual CPT/HCPCS rate?
In the CDID’s rates column for the CPT/HCPCS codes.
Name the reason an ambulance claim may pend with PRP38 for manual intervention.
A cancelled trip
According to the RFI training, which form must you update once the RFI is received?
The CRM form